The Shoulder Exam

Look

• position – e.g. the internal rotation of a posterior dislocation
• asymmetry – deltoid, winging scapula
• scars, sinuses, swelling (anterior axilla)

Feel

• temperature (warmth), tenderness, swelling
• accurately localise bony points – clavicle, acromioclavicular joint, humoral head
• tendons – bicipital groove

Move (examine from behind)

• limitation (restricted ROM)
• ± pain
• ? crepitus
• active movement
  • raise both arms sideways
  • raise both arms forwards and backwards
  • move arm across front of body
  • rotation (arms by side)
  • neck
• passive movement
  • press firmly to fix top of shoulder
    • abduction: 90°
    • adduction: 50°
    • flexion: 80°
    • extension: 65°
    • external rotation: 90°
    • internal rotation: 90°

Examine for Muscle Power:

• deltoid: abduction against resistance
• serratus anterior: get the patient to press with their hands against resistance (e.g. against a wall) and look for any winging of scapula
• pectoralis major: hands on hips

Joint disorders

• glenohumeral osteoarthritis
• acromioclavicular (ACJ) arthritis

Rotator cuff – evidence of:

• tendonitis
• tear / rupture supraspinatus, other cuff muscles
• frozen shoulder
  • scapulothoracic rhythm
  • glenohumeral rhythm

1. difficulty initiating abduction
2. reduced range of motion
3. painful arc
   1. early range: deltoid / supraspinatus
   2. mid-range: rotator cuff / supraspinatus tear
   3. end-range: ACJ arthritis
   4. painful limitation in all directions: intra-articular
   5. no pain / weakness –  tendon rupture (vs. neurological)

Consider referred pain from:

• cervical spondylosis
• mediastinal pathology
• cardiac ischaemia

X-Ray

• AP
• axillary – arm rotated relative to glenoid cavity
  • subluxation / dislocation
  • joint-space narrowing
  • bony erosions
  • calcification soft tissues
  • look at ACJ